Search for tag: "sinus"

Interviewer: You've tried the sprays and the pills for your seasonal allergies, but they just don't seem to work. So what are the next steps to finding allergy relief?

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's really good with allergies too. So in our previous conversation with Dr. Oakley, we talked about managing those symptoms with prescription and over-the-counter sprays and other medications. If you haven't listened to that podcast, be sure to check that out first. But Dr. Oakley, if those sprays and pills aren't working, what are the next steps that you would take with a patient?

Dr. Oakley: The main next step that we generally talk about with patients is allergy testing, and that is identifying what the patient is specifically allergic to or the things, you know, they're specifically allergic to. And the goal behind doing that allergy testing and the reason we don't necessarily do that upfront is because the main goal is kind of a step towards the immunotherapy option. And this is a treatment for allergies that can be very effective for a lot of patients who, you know, are still struggling after medical therapy. And the idea behind it is basically desensitizing your immune system to the allergies, so it's less reactive to that allergen or those allergens.

Interviewer: And it seems like most people I talked to that have allergies, they'll be like, "Oh, I need to go get my allergies tested." In their mind, it's the first thing that you do. Do you find that to be common?

Dr. Oakley: I do. Yeah. I get that question actually a lot, "Should I be allergy tested?" And it's certainly satisfies our curiosity in many cases of, you know, what we're allergic to, but it doesn't necessarily change the treatment if we haven't done those medical management steps yet, because if, you know, whether you're allergic to this specific pollen or that specific, you know, weed, or this tree, or that grass, you're still going to be using those as, you know, your earlier steps. You're still going to be using, you know, those nasal steroids sprays first or the oral antihistamines first and the antihistamine sprays first, because that has, you know, a broader effect, you know, on all of those.

So that's what we generally don't do that upfront, because it doesn't necessarily change our first couple steps and, you know, the treatment. But it does affect, you know, our later steps. If we're thinking of immunotherapy, we need to know what we're specifically treating for that to work. And so that's kind of where it comes in and the point behind the testing, you know, at that stage generally.

Interviewer: Yeah, so your patients that you take at that point to the testing stage, I'd imagine they're just not finding any sort of relief from the first steps, or their allergies are just so terrible. I mean, what kind of patient then makes it to the testing stage usually? You're able to . . . I would imagine the medical things that you do first, the sprays and the pills take care of a lot of what patients experience.

Dr. Oakley: Yeah. I would say the patients that generally get to that next stage are those that are getting either really severe or really bothersome seasonal allergies that are refractory to the medical therapy. And they just don't want to, you know, suffer every summer, all summer or every spring, all spring. Those are good candidates for immunotherapy. They're getting breakthrough symptoms despite those, you know, medical treatments.

Other patients will have year-long allergies because they may be allergic to, you know, dust mite, and it's all around them. It's in their house. And, you know, there are things they can do, like, you know, try cleaning their house really well. However, we've not seen that those things will fix the problem in a noticeable way. They'll still get their symptoms. And so, you know, those patients are suffering all year, and, you know, there are immunotherapies that can help with those perennial allergies.

An additional option, for example, would be a patient who has a cat that they're allergic to, but they're very, you know, emotionally connected to their cat. It would be distressing for them to get rid of their cat, or it's a partner's cat and, you know, they can't necessarily avoid it. It's not so easy to always get rid of a pet. So that'd be another case where immunotherapy may, you know, play a good role for that patient.

Interviewer: When you get to that point, you do some of the testing, and then after you get the results, how do you proceed to the immunotherapy and how does that work?

Dr. Oakley: So generally, we're identifying the allergies that are causing, you know, the sensitivities that the patients have based on how they respond to, for example, skin prick testing, which would be the most commonly used allergy testing upfront. It can be done, you know, in the office. Patients are tested for multiple allergies at once usually on their arm. You're using a grid system to see what skin responses are the most significant to determine what they're, you know, most allergic to. And those are the allergies that you target, you know, their worst reactions with the immunotherapy. And the idea behind the immunotherapy is giving them very small but ramping up doses of that thing that they're allergic to, to just gradually desensitize the immune system to it.

Interviewer: I remember getting those as a kid. I've had more success with the first line of defense in later life, with some of the new medications that came out, I don't know, probably 20 years ago now, but I say new. So like my experience was the immunotherapy didn't really help me. Do a lot of people experience success with it?

Dr. Oakley: It's generally considered to be 80% to 90% effective. But, you know, it's not 100% effective, as you said. So some people don't get that response. It's generally very effective, but it is a commitment. It's very much a time commitment. You know, it's a three to five-year treatment where patients are coming in anywhere from a weekly to a . . . or I should say anywhere from a twice weekly to a monthly basis for injections, you know, to get that benefit.

Interviewer: Yeah. I remember it was twice a week I'd go in and get those allergy shots. So if immunotherapy doesn't work then, then it sounds like the last option is surgery, and I didn't even know there were surgical methods for allergies. Talk about that.

Dr. Oakley: Well, I should clarify because surgery is more of an assistive option.

Interviewer: Oh, okay.

Dr. Oakley: So not so much a treatment. It doesn't specifically cure or treat allergies. It helps with the symptoms, but in and of itself would not be sufficient. It goes along with these other treatments. So surgery can address some of the more bothersome nasal obstruction symptoms. For example, well, let's just say specifically from anatomical factors, like a deviated septum or enlarged turbinates, which are, you know, shelves of tissue in the nose that warm and humidify the air but can get quite enlarged with allergies. So treating some of those anatomic, you know, factors can improve symptoms of nasal congestion, but you need to treat the trigger as well, the ongoing allergy trigger. So that's that medical management or immunotherapy as well. So the surgery helps, but it's not a treatment in and of itself.

Interviewer: If somebody is listening to this and you just would want them to take away one thing after we're done with our conversation, what would that be?

Dr. Oakley: The main thing I would say is don't suffer in silence. This is a really common problem with many options for treating it. We know from, you know, research study after research study that there is a significant improvement in quality of life when these allergies are managed appropriately in patients rather than just struggling with really bothersome and really distressing, you know, symptoms on a day-to-day or seasonal or yearly basis. You know, try some of these easier steps. Don't hesitate to come in and get some, you know, formal consultation and talk about other options that can really, really benefit you.

Interviewer: Getting a better understanding of the long-term effects of poor air quality in Utah. That's next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Heidi Hanson is a researcher that studies poor air quality and its adverse health effects. Heidi, when you look outside on one of our inversion type days, knowing what you know, what goes through your mind? Because I'd imagine it's a little different than what goes through my mind because of what you do know.

Heidi: Yeah, so I know that it's not great to be out there and it concerns me for a lot of the populations, especially the long-term effects of it. If a child's being exposed in utero, what are the long-term effects of this bad air quality? I'm thinking a lot further down the road. We also want to think about, obviously, our young children are a sensitive population and then older individuals as well.

Interviewer: Why young children? Is it because they're still developing?

Heidi: Yeah, yeah. So they're sensitive at the time of the exposure, but they're also sensitive for other reasons as well. So they're going through a period of development and so any environmental exposure to them may have long-term adverse effects. Because they're still developing, they're still growing their . . . environmental shock may really affect them in a long term and what we call that is a critical or sensitive period. When a child in utero, or is a fetus, they're going through a lot of rapid development at that time and any sort of environmental shock or exposure can change the way that they're developing.

And what we call that is scarring. Basically what that is, is that's a change to them that cannot be reversed. And for childhood, we usually we call it a sensitive period. So it's not quite as a critical growth period, but it's sensitive to environmental exposures, a lot more sensitive than an adolescent or an adult.

Women are another population that may be affected more than men by the poor air quality. And so that's something that's very interesting to look at the sex differences and really understanding if women are, what are those mechanisms? Then, another population that I've been working on with Dr. Anne Kirchhoff and Dr. Judy Ou at the Huntsman Cancer Institute is looking at cancer survivors. So trying to think through how cancer survivors are affected by bad air quality as well.

Interviewer: I guess I'm fairly fortunate the fact that I'm a male and I'm an adult and I don't have respiratory issues so, quite honestly, a lot of times I go out and I can smell the air, and I can see the air and I don't like the air, but I don't know that it affects me, really. Is that accurate or is it, "Oh, yes, it affects you, Scott"? What's your answer to that?

Heidi: I think it probably affects you a little bit more than you realize. So yeah, you may not have an asthma event or an asthma attack, but it's really . . . I don't know if you've noticed your nose running a little bit more or your body reacting because there are foreign materials going into your body that it's not expecting to deal wit. And your body does have to deal with them in some form. Even though you're not having an event that's taking you to the hospital, it's still affecting your health in some way.

Interviewer: Yeah, that would make sense. You look out and you look at that air and you go, "That can't be healthy," and the research shows that that's indeed the case?

Heidi: Absolutely. There is so much research on this topic and I really think it's pretty hard to refute that there are adverse health effects that are associated with air quality just because of the volume of research that's pointing to this. Not only is it just epidemiological research, but we're looking at animal models and you're seeing the same kinds of things. We're seeing there are definite effects to their quality. Even things you wouldn't necessarily think of, like your fertility. We're seeing there are studies out there showing that bad air quality may affect semen quality in men or bad air quality may affect fecundity for women. It's not just like your normal things, asthma, cardiovascular disease, but it may be affecting a lot more than just that.

Interviewer: And other stuff that we don't even realize.

Heidi: Right.

Interviewer: I know when you're doing research, when you're dealing with anything environmental, it can be very difficult because there are a lot of things in the environment. When you're looking at the effects of air pollution on the populations you're looking at, how do you know that it's air pollution that's causing it? How do you figure all that out?

Heidi: Yeah, so that's extremely difficult. A lot of what we are doing is with some of the methods we can do so you're comparing an individual to theirself in the statistical methods that we're using. And so what that does is that pretty much makes it so that anything we're not able to observe is kind of taken out of the equation. Basically, we're looking at the only things that are changing for that person on that day is their exposure to the air quality.

Air pollution is this amazing thing in Utah so we have this natural laboratory for doing this type of work where we have very clean air days and we have terrible air days. It leads to a kind of a perfect set up for this kind of research where there are strong environmental exposures that are well documented to have. There are biological mechanisms that are plausible that make us think this really may go on to have later life effects.

Interviewer: How do we get to a point where more people care? How do we get to a point where somebody . . . do you feel that we get to a point where somebody like me goes outside and I go, "This is terrible. We've got to do some about this," and then goes on with their day to day? Versus the people that are passionate about it are trying to make change. How we get more people like that?

Heidi: I think people really need to understand that this not just an acute effect. It's not something I'm only dealing with today and then tomorrow it's gone and it's okay. But if people really start to realize that what they're being exposed to may affect them now. It has potential to affect them long-term, especially when they start to get older. But not only that, it really has the potential to affect multiple generations.

If people are concerned about the health of their children and their grandchildren, they should be concerned about the air quality right now. There are studies that are just starting to come out showing there may be epigenetic changes related to air pollution. Basically, what they're saying is that air pollution may affect you, but it also may affect your sperm, which may go on to affect your children, or your grandchildren, or that exposure in utero may lead to epigenetic changes that go on to affect that child and also that child's child.

This is all newer research and so that has to be considered when you're thinking about this. But there is potential that this goes on to affect generations and it's not just that the only person that's affected it's you on the day of bad air quality.

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Dr. Miller: Allergies, colds or something else? How do you tell and how do you treat them? That's next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Jeremiah Alt. He is an ENT surgeon. That's an ear, nose and throat surgeon. He's a member of the Department of Surgery here at the University of Utah. Jeremiah, how does one tell the difference between an allergic symptoms of nasal discharge versus a common cold or sinusitis? Is there a way to sort of know if you have one or the other?

Dr. Alt: Yeah. That's very difficult. Even very difficult for the physician to figure that out in many cases and requires a thorough history with the patient to figure some of these things out. In general, allergic rhinitis if it's seasonal will occur during the season, where if you have hay fever, you'll get itchy eyes and a runny nose.

Dr. Miller: I always think of hay fever as being itchy.

Dr. Alt: Right.

Dr. Miller: Right? So people are scratching the corners of their eyes and they're blowing and sneezing.

Dr. Alt: Right.

Dr. Miller: The back of the throat is kind of scratchy. Sometimes when I think of the common cold or sinusitis that doesn't feel very itchy. That's [inaudible 00:01:15].

Dr. Alt: Right. So the common cold will have some of the similar symptoms, as there's definitely overlap where you can have increased congestion and nasal blockage. You'd probably be more likely, though, to have some facial pain and pressure. We commonly talk about the loss of smell occurring with sinusitis. But this can also occur with allergies as the inner lining inside your nose is swollen and angry, and inflamed and it can block off some of the ability to smell.

One of the big differences though, is we commonly think of discharge. So if the discharge is yellow or green, this is more signs that this is more severe than just an allergic reaction.

Dr. Miller: More inflammation, more at that issue of infection in the sinus.

Dr. Alt: Correct.

Dr. Miller: So one goes to the store to self-remedy what they would consider to be a fairly short course of this problem. If they have rhinitis, that is the itchy symptoms, what should they be using to treat that problem with? I think most of the medications now are purchased or can be purchased over the counter.

Dr. Alt: Correct. The oral antihistamines are a great option, and they've been used for many years. The second generation are non-sedating, like the Benadryls were that can make people very tired. Although, the second generations can make some people tired.

Dr. Miller: I've taken Benadryl and it works as an antihistamine. But man, does it knock me out. I think it does the same with some people and some people, they don't seem to have that fatigue that I get or that a number of people will get.

Dr. Alt: Correct.

Dr. Miller: Now, I've heard with Claritin, which is an example that comes generic as loratadine, that it's not sedating. But do you think it works as well as something like Benadryl or diphenhydramine?

Dr. Alt: Well, partly it's also what we're targeting. The itchiness, I think, works great. Another great antihistamine is Zyrtec. So if the patient has the itchiness with the runny, drippy nose, what we call clear rhinorrhea, or clear, drippy nose, the Zyrtec is actually quite more drying than let's say the Claritin. So we would push the patient more towards the Zyrtec, which is a more drying medication.

Dr. Miller: This is also listed as a non-sedating antihistamine.

Dr. Alt: Correct. One thing to consider is even if the second generations make you drowsy or feel a little fatigued, you can also take them at night which is an option.

Dr. Miller: So sleep a little better and maybe get a little bit better coverage for the allergic symptoms.

Dr. Alt: Yeah. A third option that's more recent is a topical spray antihistamine. This is not taken by the mouth and you can spray it in the nose. This type of antihistamine, I've never seen it cause drowsiness or fatigue in patients, and you can use it on contact. So if you know you're going outside you can quick spray it in your nose to reduce the antihistamine response that you have for your allergies.

Dr. Miller: So Jeremiah, does that require a prescription or is that available over the counter?

Dr. Alt: That one is still a prescription medication. So you really need to get that from you allergist or your ENT, or your primary care doctor.

Dr. Miller: Now, there's another class of medication used to treat allergic rhinitis as well, and that would be the nasal steroids.

Dr. Alt: Yeah. So the nasal steroids actually have great evidence to be used both for allergic rhinitis and for many of the diseases that we talked about in some of the other podcasts, including chronic rhinosinusitis or reoccurring acute rhinosinusitis, where there's just an overall inflammation inside the sinonasal cavity. This just calms the inside of the nose down. It's a topical steroid. It's sprayed within the nose, usually dosed once or twice a day. What I like to think of it, it addresses the root of the problem.

Dr. Miller: The inflammation.

Dr. Alt: The inflammation, correct. So it really reduces the overall amount of goblet cells in the nose, the inflammatory, or those mediators in the nose and the immune system that are really creating the immune system to start with to create this inflammation.

Dr. Miller: Now, do you think that a patient with allergic rhinitis could also take the antihistamine orally, antihistamine nasal spray, and a topical steroid nasal spray, or should they use them separately? What's your thought on that?

Dr. Alt: It really depends on the patient's response and the overall diagnosis that you've come up with your doctor and your treatment plan. However, commonly we like to use both and we feel like patients get a good response by both blocking with an antihistamine and using a topical nasal steroid like Flonase or Nasonex.

Dr. Miller: Both of which they could get over the counter.

Dr. Alt: Correct.

Dr. Miller: It's possible that they could start their own treatment and then if things weren't going well they could end up seeing their physician.

Dr. Alt: There is a new medication, Dymista, that has actually combined the two together. So you can get it in a single spray, which patients are noting that they've really enjoyed using just one medication instead of two separate.

Dr. Miller: Now, let's say they have the common cold or sinusitis. Do the same medications work?

Dr. Alt: Yes. In general, though, we don't typically use antihistamines for chronic sinusitis unless they have a comorbidity or that's one other disease process that they also have on top of the chronic sinusitis that we want to help control symptomology. So if they have allergies and we want to help control some of that drippy nose, postnasal drip symptoms, we can add on an antihistamine. But, yeah, the steroids are great, as we talked about. It's really disease of inflammation, so that topical nasal steroid is ideal for helping.

Dr. Miller: Would you recommend using an oral, what we call, sympathomimetic, like pseudoephedrine or Sudafed for someone who has the common cold or sinusitis?

Dr. Alt: Those are really two different diseases and two different applications for that. For an acute onset cold or viral rhinosinusitis or bacterial, this can help make the patient feel better. I don't think it really helps get you over the illness quicker. But it can help improve your overall well-being. Now, in sinusitis it can also improve your overall feel of increasing your ability to breathe through your nose.

But this doesn't get at the root of the cause of the disease itself, and we commonly don't like to think of using these long-term in a disease like chronic rhinosinusitis, which is a chronic condition. You'd have to use this over potentially months and years, which we're concerned about the possibility of hypertension.

Dr. Miller: Now, you could also use the same medication as the nasal spray for a few days, I understand.

Dr. Alt: Afrin or over-the-counter oxymetazoline is a great sympathomimetic, which really reduces the overall swelling inside the nose. We commonly like to really counsel the patient that these are great short-term. So these are two to three-day treatment options, and then they really need to consider trying to come off of them.

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updated: February 19, 2019
originally published: December 1, 2015

Dr. Miller: So you have a deviated septum. Does that need to be fixed and what symptoms does a deviated symptom cause? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ear, nose and throat physician. He's also a professor here at the University of Utah and a member of the department of surgery. Jeremiah, what's the story of the deviated septum? What is a deviated septum and, if you have one, do you always need to have it fixed?

Dr. Alt: We commonly have patients who come in with complaints of just simple nasal obstruction. Commonly, we have to go through the differential diagnosis of what that is.

Dr. Miller: You mean they can't breathe out of one side or both sides of their nostrils, is that right?

Dr. Alt: Yeah, correct. As a rhinologist, I commonly see patients with sinus disease and congestion and allergies. It also commonly comes up that they just have what's called septal deviation and the septum itself separates basically the right and left side of the nose.

Dr. Miller: So it's your nose bone?

Dr. Alt: Yeah. It's made up of both cartilage bone. The septal deviation can occur just from normal development as everything is not perfectly symmetric as we develop. So it can be deviated to one side or the other. It can also occur from trauma.

Dr. Miller: Getting boxed in the nose.

Dr. Alt: Getting boxed, vehicle accidents, getting bumped in the nose. So after the trauma, this is an acute event, someone would come and say, "I can't breathe out of the right side of the nose," after getting bumped or something that's been there their whole lives and they've just noticed that they're having increased trouble breathing, they can't sleep as well.

Dr. Miller: I'm curious, is deviated septum mostly due to trauma or are people born with it?

Dr. Miller: I think the majority is they're born with it or we have a known etiology of why it's deviated.

Dr. Miller: Okay. So the come to you and they complain that they have difficulty breathing out of one side of the nose or the other or maybe both. At what point do you say, "Well, look, maybe we can repair this surgically if you need to have it repaired"?

Dr. Alt: A lot goes into talking about the deviated septum. In many instances, it's found incidentally, which means we look in their nose and they have a deviated septum but they don't describe nasal obstruction.

Dr. Miller: And under those circumstances, you probably wouldn't recommend surgery?

Dr. Alt: Correct. In those situations, I don't even like to bring it up because then it's something that patients start to worry about. But if it's significantly deviated and we look at it and we assess the patient and it's significantly closing off one side of the airway, we can discuss different surgical options and how to correct that.

Dr. Miller: I have a question. How often do people come to you to looking for cosmetic reconstruction of that bone?

Dr. Alt: That bone itself is usually not cosmetic. It's functional. It doesn't correlate into how the nose looks.

Dr. Miller: So that's a whole different type of surgery.

Dr. Alt: Correct.

Dr. Miller: Not to be confused with the symptoms that a deviated septum would cause.

Dr. Alt: So that's really talking about what we usually term open septorhinoplasty is where were able to change the look of the outside of the nose or [Inaudible 00:03:12] and changed inside the nose for functional breathing, which sometimes we do in combination if the nose is broken or twisted on the outside, we also have to fix the outside in addition to the inside.

Dr. Miller: So how often do you find the patients with need to have surgical correction for a deviated septum?

Dr. Alt: It's actually quite common. It's one of the most common procedures we perform. Not only is it bothersome in the sense that they can't breathe but it substantially affects patients quality of life, which has been shown over and over again by improving the way we breathe through our nose substantially affects how we feel in our day-to-day activities. And this is most likely partially contributing to the way we sleep and the way we get good night's sleep. If we can't breathe through the nose, it forces us to breathe through the mouth and we may have more obstructive events and it can also potentially lead to what we call obstructive sleep apnea.

Dr. Miller: So how do you do the surgery?

Dr. Alt: So there are several options to do surgery and one that we're doing more and more that gets great results is doing endoscopic septoplasties. So it's using angled and straight, rigid endoscopes with that special high-definition camera. And we're able to make very specific and delicate incisions within the septum to take out those crooked parts and so there are no external incisions on the nose. It's all done on the inside of the nose and we feel that patients get great functional responses and, at the same time, have quicker healing.

Dr. Miller: Now, do you tell your patients that they are going under general anesthesia? Do you put them to sleep when you do these or is it a local sort of anesthetic you use?

Dr. Alt: Yeah. I would not recommend local and patients probably wouldn't like me very at the end of the procedure. So we really counsel the patients that these should be done under general anesthesia where they're totally asleep, they're not moving. We have the ability to take our time and do the job correctly.

Dr. Miller: What's the recovery like?

Dr. Alt: Really, the recovery's not too bad. We normally tell the patients they'll probably have to take pain medications for two to three days. Commonly, these type of procedures used to be packed with nasal packing. We no longer pack the nose. We moved into placing splints on the inside of the nose like flexible plastics splints, but even now we're even moving away from that. So many times, we can get away with doing the what we called endoscopic septoplasty without putting any packing in the nose and so this helps patients feels better and recover quicker too, as they're not obstructed with something in their nose we don't have to take out in a week. Usually, at a week, at that point, the patient feels great, usually back to light activity. At two weeks, you're completely healed.

Dr. Miller: Now, for a patient who is going to primary care physician, is a primary care physician usually able to tell if they have a deviated septum or do they usually refer them to make that diagnosis?

Dr. Alt: I think in general, you can determine what we call a caudal septal deviation. It's more towards the front of the nose because you can just look at it with the simple measure of using the nasal speculum looking at the front of the nose and you can tell if it's deviated. Interesting enough, those septums that are more deviated or caudally towards the front of the nose actually usually need a more significant type of surgery, which we'll discuss with the patient, but that usually actually leads to what we call an open septorhinoplasty.

Many times, the posterior septal deviations are easier to fix endoscopically and those are actually harder to diagnose because you need to see further into the nose. So seeing someone like an ENT or rhinology person like myself, we're able to use scopes to look at the septum more posteriorly in the nose to diagnose it.

Dr. Miller: So in conclusion, what three things might you told the patient that would lead them to your doorstep to where you would make a diagnosis of a deviated septum?

Dr. Alt: I think the first thing is if they're having trouble breathing through their nose. Typically, it's unilateral, but it can be both sides, bilateral. The next thing is if this is causing significant changes in how they feel and how they function during the day, if the obstruction's bad enough where they feel like they need some improvement. And third, which we didn't mention, but I think should be mentioned here conclusion, is that many times, medical management can improve nasal obstruction even with septal deviation. So commonly of pretrial of medical management needs to be done before you start discussing . . .

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updated: January 23, 2019
originally published: November 11, 2015

Dr. Miller: When does short-term sinusitis become long-term or chronic sinusitis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ENT surgeon, Ear, Nose and Throat Physician. He is in the Department of Surgery here at the University of Utah. Jeremiah, all of us, or most of us, I would think, have had acute or sudden onset sinusitis and most of that is due to viruses that last a few days to a week or so and then goes away. When does that become chronic sinusitis? What is chronic sinusitis?

Dr. Alt: Something we commonly see in my practice as a rhinologist, we commonly describe acute sinusitis is either viral or bacterial. And these are really short-term. These consider viral up to seven days and if they're lasting over seven days, then you can start considering this to be potentially a bacterial rhinosinusitis. And, commonly, that's when your provider is going to prescribe an antibiotic. It's normal to have two to three episodes of these either viral or bacterial rhinosinusitis a year in general amongst the population. The concern becomes when these occur more than four times a year. When they occur more than four times a year, we start to come into a category of sinusitis that needs a little bit more specialty care and this is called recurrent acute rhinosinusitis.

Dr. Miller: Now, this is different than what people would experience during an allergy season. It's not just runny nose or itchy nose and sneezing. I mean, you've got pain, discomfort and post-nasal drip and basically during sinus inflammation you don't feel very good.

Dr. Alt: Yeah, that's correct. We commonly really describe this with four big symptoms that I like to talk about and one is nasal obstruction or congestion. Another is a loss of the smell. Third is facial pain and pressure that the patient has during these episodes.

Dr. Miller: Is there any particular place that they'll have the pain?

Dr. Alt: That's some of the studies that we're doing that we quite don't particularly understand, which is a misconception that pain in pressure behind the eyes or underneath eyes correlates well to a sinus infection. That's just not true per se, although . . .

Dr. Miller: I suspect that's also true with headaches. I know there's been this association and I'm not sure that's clear association.

Dr. Alt: Correct. And so commonly we need to do further imaging or testing and to determine if their facial pain and pressure are really due to a sinus infection. And the difference really between acute and chronic then is really about the time course. So acute, we're talking about seven to 10 days. And chronic is really what we describe the something that occurs over 12 weeks. So this is a long, drawn-out infection that they continue to have congestion/obstruction, loss of the smell, facial pain and pressure. And it's not cleared by medical management, which what I mean by that is antibiotics or oral steroids or rinses for the nose or decongestants. And they continue to have a substantially reduced quality of life during this time.

Dr. Miller: How do you deal with if they've had several courses of antibiotics or course of steroids and they're still plugged up, so to speak? What the next step there?

Dr. Alt: Well, part of the issue is, what is the etiology of chronic sinusitis. And the etiology of chronic sinusitis isn't completely known. Many different things can be contributing. This probably has to due to an array of different competing factors, such as allergy or environmental exposure of the poor air quality, could be due to a non-immune issue. So what I'm getting at is the underlying cause of chronic rhinosinusitis is not the bacteria itself or the infection, it's really a disease of inflammation that we're just beginning to understand.

Dr. Miller: When they make it to your doorstep, you end up treating them again medically to see if that works? I know sometimes the duration of the antibiotic course is not necessarily long enough. Sometimes it might help to do both antibiotics and steroids to reduce the inflammation as you speak about. But it sounds like maybe you . . . do you give them another chance of medical therapy before you start talking about surgical correction?

Dr. Alt: Yeah. We normally like to discuss what we consider maximum medical management for patients with this disease. And that really entails four big things that most of the rhinologists across the United States agree with. Recent surveys in 2007 and 2013 looking at all the rhinologists across the United States, they really kind of agree on four big things. And those four big things are was the patient treated with an oral antibiotic. Yes or no? If no, they need to be on it. The next is basically topical corticosteroids. These are drugs you probably heard in the news with Nasonex or . . .

Dr. Miller: Are now over the counter, as I recall.

Dr. Alt: That's correct. Now they're over the counter. So this is a second thing that patients really need to be on. The third is actually some type of high-volume irrigation in their nose. So they're irrigating their nose out with some type a sailing solution. And the fourth would be oral steroids, particularly in those patients where we diagnose as chronic sinusitis with nasal polyps.

Dr. Miller: What about the use of topical sympathomimetics like Afrin that you could buy over the counter? I think some people find initially that that works pretty well. Is there a problem with long-term use of that?

Dr. Alt: Yeah. So short-term use, I think these can be very beneficial to the patient with improving the nasal obstruction and congestion that they feel. And it may also open up the sinuses some to help deliver medication. However, we commonly discourage long-term use of these because they can be somewhat addictive to your nose where your nose can become more inflamed and release more mucus, causing overall longer term deficits with that medication.

Dr. Miller: So let's say that you take with position through the four steps that you've outlined and they don't respond to therapy. What would be the next step?

Dr. Alt: So the next step is an honest discussion of how this is really affecting their overall quality of life. Because the next step we commonly think of is surgery. And surgery isn't a cure for chronic sinusitis, but it does help improve the medical treatment of chronic sinusitis. So I like to really discuss that this is overall an elective procedure. If their chronic sinus disease is affecting them enough, which we know it is just as severe or more severe than those on kidney dialysis or diabetes or hip replacement, so we know it really affects a patient's quality of life. So surgery gives them the opportunity to basically, what I like to term, hit the reset button to help open up the sinuses to help us deliver better medical care.

Dr. Miller: What percentage of patients with chronic sinusitis does end up with surgery as a potential treatment?

Dr. Alt: I think it depends on the surgeon and who you're talking with. I would say here at the University of Utah, we normally deal with more complex cases. Patients many times have already had one or two surgeries and they've been treated with multiple rounds of different types of medical therapies. So in my practice, I would say the majority end up needing some type of surgical management to get to hold off the problem. In the community, it just depends. You can have great response with a thoughtful program and medical treatment for your chronic sinusitis. It doesn't always need to have surgery.

Dr. Miller: So in conclusion, what would you tell a patient who is seeing one of the primary care physician, in terms of when might it be time for them to head on over and seek your expertise?

Dr. Alt: Yeah, as we talked about in the beginning, I think it is . . . really need to consider how many times a year you're getting sinus infections. Is it four or more? How long do you have the sinus problem in general? Is it seven to 10 days or do they really stretch out between one month, three months? And definitely if the disease is stretching onto that two or three months, you probably need to see a specialist.

Dr. Miller: I'd like to put a final plug in and I'll see if you agree with me that if you have acute sinusitis, sudden onset sinusitis that lasts only a week, you shouldn't necessarily be asking for antibiotics.

Dr. Alt: Yeah, that's a great point, the common misperception of that. I think we overprescribe antibiotics and patients commonly feel they have a sinusitis. But with a good medical physical exam, many times it's viral and you can wait. Now, you have to be cautious and every patient's different. Many times, you can have complications from a viral sinusitis. So it's depending on the patient, but overall, in general, you're right.

Dr. Miller: Generally up to seven days.

Dr. Alt: Yep. If it clears in seven days you do not need an antibiotic.

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Interviewer: How do you know if endoscopic sinus surgery or just sinus surgery is right for you? We'll talk about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: The purpose of this podcast is to help you understand if sinus surgery might help the issue that you're suffering from. You may have already done some research on the internet or have been to a doctor and they told you a few things, you may have forgotten some stuff or want a second opinion, and that's what we're going to find out. We're going to find out some basic information if sinus surgery is going to help your issue.
We're with Dr. Richard Orlandi. He's an expert in this thing at University of Utah Healthcare. Before we get into how do you know it's right for you, let's talk about how does the surgery change people's lives that do need this type of surgery?

Dr. Orlandi: The surgery can have a really big impact on the overall quality of life, not just the sinus problems. We know that patients with chronic sinus problems have a quality of life that's similar to someone in heart failure, way worse than diabetes, high blood pressure, things like that. And so what we're looking at is the overall picture, not just the sinus problems, but just not just the sinus symptoms, and so we're looking at sleep issues and the disorders in sleep.
Another thing that really affects quality of life is loss of sense of smell. We see that commonly with patients with sinus problems and the reason that's such a big deal is not only can you not smell spoiled food, natural gas, things like that, but much of what we perceive as sense of taste is really sense of smell. So when we lose our sense of smell, we really lose our ability to appreciate the food we're eating. We're looking at fatigue and we're looking at depression. These are things that are much higher in patients with sinus problems than our regular population and we're looking to really target those.

Interviewer: So people with sinus problems, not having a great life right now.

Dr. Orlandi: Absolutely not. It really impacts people in a much bigger way than we often think.

Interviewer: What sinus issues can sinus surgery help? Let's start right there.

Dr. Orlandi: Most of the time we're doing sinus surgery for people with chronic sinus problems or chronic sinusitis. It's a long-standing inflammation of the sinuses. Most people will feel symptoms of congestion, pressure in the face and in the sinuses, they're having frequent infections, those are the things we're mostly targeting.

Interviewer: Yeah. And a patient comes in generally for the infections, or is it the pain, or is it kind of all the above? Is there any one thing that they . . .

Dr. Orlandi: It's really all of the above. A lot of times we see patients because they've been to their primary care doctor over and over again for sinus problems and they're looking for a better long-term solution.

Interviewer: Okay. Are there some issues that this type of surgery won't help?

Dr. Orlandi: Yeah. I think the one that we most typically see is when patients are referred for facial pain or headaches and it's really not their sinuses. So clearly we're not going to be able to help them in that situation.

Interviewer: But in some instances that is caused by their sinuses, it sounds like.

Dr. Orlandi: It is, and so it takes doing some looking into it with an examination, with questioning, with sometimes a CAT scan to really be able to find out what's going on.

Interviewer: Yeah, and you're the expert in doing that.

Dr. Orlandi: One of them here, yes

Interviewer: One of the experts. Fair enough. All right. So beyond what issues it can help and it won't help, are there some people who are better suited for this procedure than others?

Dr. Orlandi: We usually try medications first to try to avoid surgery, and I think that's an important point. We go through people's medications, their history, what they've been on, what has worked, what hasn't worked, and really try to target different solutions for their problem. When those things have failed, then we start looking at surgery.

Interviewer: Now, are there questions somebody should ask before they consider a procedure like this or if they are?

Dr. Orlandi: I think that definitely they want to make sure that all their options have been exhausted. Obviously, surgery is an option, it's not the option. So we want to make sure that a patient is really going through all of those different options and making sure they've exhausted them. Now having said that, there is interestingly some evidence coming out more recently last year, too, about delaying surgery too long may lead to not as great an outcome. We don't know that yet and I don't think we're ready to jump into surgery, but we don't want to delay forever either.

Interviewer: I think you're showing right now again why somebody should come to a specialist such as yourself who has dealt with this before. You know, the research, the literature on that sort of thing. So, how would somebody move forward with this surgery? They've been to a specialist. What would be the next step, then?

Dr. Orlandi: Once they've been to a specialist, had a thorough evaluation, looked at all the options, and they decide to have surgery, then we go ahead and schedule that and we get everything ready ahead of time. We want to make sure that the medication is optimized at that point. Even though it's failed and they're requiring surgery, we want to do everything we can to try to reduce the inflammation prior to surgery and that, we think, leads to a better successful outcome.

Interviewer: Interesting. Are there some other things, other considerations people should think about that I haven't hit on?

Dr. Orlandi: No, I think you've hit on all of them. We really just want to get a thorough evaluation of all the options and then make a decision together. We try to make sure the patient, at least at our office we really want to make sure they understand all of the different options, the pluses and minuses associated with those, and that they really understand what the surgery is all about, what they can expect from it. Sinus surgery is not a cure. It's not like getting your appendix out. It's not like getting your gall bladder out. It's really important to understand that the surgery's important, but it's a part of their overall management. Unfortunately, sinus problems are a little bit like high blood pressure, diabetes. We manage it, we don't cure it.

Interviewer: All right. Any additional resources . . . I know somebody that might be considering this might want to learn a little bit more information. Do you have any good ones you could drive them to?

Dr. Orlandi: We've got some great information on our website here at the University of Utah at University Healthcare. We've got a number of different diagrams. Some people learn more visually, some people more reading through it, and so we have a lot of the explanations about the surgery risk, benefits and alternatives, those sorts of things there.

Interviewer: And how would they find that website? If you just go to Google and Google . . .

Dr. Orlandi: University of Utah sinus surgery, you're going to find it.

Interviewer: Going to get you right there. All right, well thank you very much. Appreciate that.

Dr. Orlandi: My pleasure.

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Interviewer: What is Endoscopic sinus surgery? We'll talk about that next on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Endoscopic sinus surgery is more commonly just referred to as sinus surgery. This podcast's purpose is to tell you what this procedure is, how it compares to some other alternatives, and if there are any risks or side effects, and how it changes people's lives.
We're with Dr. Richard Orlandi who's one of the experts here at University of Utah Healthcare and Sinus Surgery. I think when somebody goes in to get surgery, the first thing they want to know is what difference is this going to make. How is it going to change my life? Let's ask that question first.

Dr. Orlandi: Absolutely. I think that's a great question and obviously the most important one. What can people expect? You know, sinus surgery is not a cure, and that's one of the first things I try to tell people. It is going to help with the management of your sinus problems overall, but it's not going to cure them. So it's going to require additional medical therapy afterwards. But what we're talking about is going in and opening up the sinuses primarily to let them drain, let air in, get medications in there to the surface of the sinuses to try to reduce the inflammation. That's the overall purpose.

Interviewer: So when you say, "open them up", is that the problem, because usually things are little too constricted in there?

Dr. Orlandi: Yeah. What we're finding is that with the sinuses, they drain through small openings into the nose. We think of the nose as a hallway and sinuses are like rooms off of that hallway. That opening between the room and the hallway is small. It's supposed to be. But when we have long-standing inflammation, the lining, or call it the wallpaper, will swell up and block off that doorway so things can't get in. Air can't get in and the secretions in the sinuses can't get out and that sets us up for chronic sinus problems.

Interviewer: Does that kind of turn into scar tissue? Is that what's going on?

Dr. Orlandi: No, it just stays really inflamed and it just won't, that inflammation just won't back down.

Interviewer: No matter what you do.

Dr. Orlandi: Absolutely. We try different things with medical therapy but when that doesn't work then we start looking at making the openings wider.

Interviewer: So somebody that's suffering this type of thing that this surgery might help, it makes a significant impact to their quality of life after they have it, from what I understand.

Dr. Orlandi: It's a huge impact. Sinus problems we know are correlated with sleep issues, with depression, with fatigue, not just the sinus symptoms themselves, and so when we get that sinus inflammation under control through a combination of surgery and medications, we're able to reduce those factors in people's lives as well.

Interviewer: I've heard they refer it to as endoscopic sinus surgery. You have told me that it's just sinus surgery, that all of it is endoscopic, which indicates that at one point it was different. So what exactly is endoscopic and how's that compare to the way things used to be done?

Dr. Orlandi: The endoscopic refers to using a scope. It's like a fiber optic-type scope that we use that goes through the nostrils. Previously sinus surgery was done by making incisions underneath the upper lip, alongside the eye, between the eye and the nose, and up in the forehead and the hairline. Rarely those things are still done for unusual circumstances, but now everything is pretty much done through the nostrils.

Interviewer: So a lot less invasive.

Dr. Orlandi: Obviously, yes, and much easier to tolerate, much less painful afterwards.

Interviewer: Gotcha. What are some of the risks or side effects that somebody should be aware of if they're considering this type of surgery?

Dr. Orlandi: Knowing those risks is important as you weigh the risks and benefits, obviously, and make a decision about sinus surgery. The sinuses are right next to the eyes and they're right next to the brain, and those two areas we worry about during sinus surgery. We think about it as sinus surgeons and make sure that things are safe. Injury to the eyes, including damage to the vision, and injury in the brain that could lead to a spinal fluid leak are the two things we worry about, and those are fortunately extremely rare. But any surgeon is going to have that in the back of his or her mind.

Interviewer: Yeah. It sounds kind of terrifying, but out of all the procedure you do, just not likely.

Dr. Orlandi: No, far less than 1%, and that's important to know.

Interviewer: Gotcha. What about some side effects afterwards?

Dr. Orlandi: Clearly, like many surgeries, we're going to make the problem worse for a few weeks or months before we make it better. So more swelling, inflammation, obviously people are going to be bleeding from the nose. Some surgeons will use packing, others do not. Most of the packing that's used now is dissolvable to try to cut down on bleeding. But those are some of the things that we look at immediately after surgery.

Interviewer: Singers or people that use their voice for a living, are they concerned that that's going to change?

Dr. Orlandi: Luckily, not a huge impact, but the voice does resonate through the nose and sinuses, and for a professional singer or someone who spends a lot of time with their voice, like yourself, we are going to see that the voice will change slightly in how it resonates.

Interviewer: Yeah, maybe for the better, in my case.

Dr. Orlandi: It can be for the better.

Interviewer: All right. What are some alternatives to surgery? If somebody just goes, "Gosh, I don't know. This seems like a huge commitment," what else can be done?

Dr. Orlandi: Yeah, the surgery, very rarely are we're dealing with a life or death problem here, right? So the surgery is always as an option but not necessarily does one have to have it. Continuing with the medical therapy is always an option and a lot of patients elect that. The surgery, obviously, isn't appealing for some folks and we certainly understand that.

Interviewer: And the benefits, though, in some patients, tell me a personal story of maybe somebody that had just some great results.

Dr. Orlandi: Yeah, I think that we see people when often they've gotten to that point where they just are done with, they've done everything, has gone as far as they can with the medical therapy, with medications, rinses, sprays, antibiotic pills, even steroid pills, and they're just not getting there. We're able to take a patient like, that open things up, and then get that medication accessing the sinus surface and keep that inflammation down. And you're taking someone who's . . . again, that fatigue and depression can really be an issue, and it really helps people out in addition to resolving a lot of the inflammation and pain and pressure in the sinuses.

Interviewer: This is your opportunity to address any myths or misconception that people might have about this procedure. What are those?

Dr. Orlandi: You know, a couple of them. One is that - and we talked about this already - that I'm going to have my surgery and it's going to cure my sinus problem. I'd love to believe in that myth, but unfortunately it's just not true. We talked a lot about, I hear people talk about I'm going to have my sinuses scraped. Yeah, that doesn't sound very good, does it?

Interviewer: No.

Dr. Orlandi: And what instead we find is, what we're doing is actually opening up the holes that we talked about and actually really preserving that natural lining. We want that lining there because if we scrape it out, not only does it sound horrible, but it's going to lead to more scar tissue. So we're actually very careful to preserve the function of the sinuses.

Interviewer: We've covered a lot of ground in what is sinus surgery or endoscopic sinus surgery. Is there anything that I left out that a patient might want to know about this procedure?

Dr. Orlandi: No, I think that maybe the last thing that's important is, you know, when you have your gallbladder taken out, you have it taken out, you're cured, you may have one visit with your surgeon afterwards to make sure everything is healed up, and you're done. Sinus surgery is not like that. It requires tailoring the medical therapy afterwards. It's very individualized. We do see patients for a few visits after the surgery, sometimes three or four or more, to really tailor their medication to make sure that they're getting the most out of the surgery.

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Interviewer: You're having sinus surgery and you're wondering how you prepare. We're going to talk about those issues next on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier healthier life. You're listening to The Scope.

Interviewer: The purpose of this podcast is to help you, the patient who's decided that you want to get sinus surgery, to understand what you can do to best prepare for the procedure. There are a lot of things to consider, like how much time do you get off work, do you need to fast before, will you need to arrange for somebody to drive you.
We're going to talk about those and other things right now with Dr. Richard Orlandi. He's one of the experts here in this type of surgery at University of Utah Healthcare. So what's the first consideration that somebody should think about or do before surgery?

Dr. Orlandi: I think the most important thing is they want to be sure about their decision, and I certainly want, in our practice we want to make sure that our patients' questions and concerns are fully addressed before they make this decision. We don't want them to have any second thoughts. And so, again, we try to address every concern that patients have and then certainly encourage them to seek a second opinion.
This is not a surgery, typically, that we have to rush into. Patients have typically had their symptoms for a long time. I think it's something that people can get a second opinion, take their time with this decision, talk to family and others who have had the surgery.

Interviewer: So if they're feeling a little uncomfortable with it or whatever that's a good indication maybe you should ask more questions beforehand.

Dr. Orlandi: Absolutely.

Interviewer: And the sooner the better, of course, because you don't lose your surgery day.

Dr. Orlandi: Well, asking those questions an hour before the surgery may be waiting a little bit too long.

Interviewer: Gotcha. What should I do leading up to surgery day and when does that all start?

Dr. Orlandi: We want the patients to have as much of the inflammation under control as possible, so we ask our patients to continue with the medications that they've been on before. We may stop them for a few days ahead of time for various reasons, but really, we think that continuing that medication ahead of time is really important to control the inflammation.
One of the other things that's really important for us and for our patients is to know what to expect after surgery, so we go through a lot of their post-operative care, actually, before the surgery to make sure they know how to rinse their nose out with salt water, take their medications, and make sure that, actually, even their medication prescriptions that they're going to need after surgery, we try to get those filled ahead of surgery so it's one less thing for them to worry about on the day of the surgery.

Interviewer: We've got a podcast, actually, that covers what to do and what you need to be aware about after surgery, so if you have any of those types of questions, not only check the information that you receive, but you could check out that podcast as well.
So are there any other considerations? It sounds like business as usual, take those medications. How far are you starting out in prep, a week before?

Dr. Orlandi: No, I think that again we're starting about a couple of weeks where we're continuing the medical therapy and then we may fine tune it within a few days prior to the surgery. But it is very similar to other surgeries where you're going to want to follow the instructions that you've been given as far as stopping eating or drinking, usually it's around midnight, sometimes a little later if your surgery is in the afternoon. Making sure someone can drive you. This is a surgery that's done typically under general anesthesia, meaning you're completely asleep. It can be done under local anesthesia if patients prefer. The vast majority prefer to be asleep, understandably.

Interviewer: Absolutely. That's a good consideration. You're going to have to have somebody to drive you home. How many days off of work should you take?

Dr. Orlandi: For sinus surgery, people typically take about a week, sometimes less, sometimes more, but on average about a week. Now if someone is having their septum corrected, the septum is the wall that runs down between the left and the right side of the nose, that septum, it's called a septoplasty to fix that. That septoplasty can actually be a little bit more painful. You're basically talking about kind of breaking the inside of the nose. Now, patients won't be black and blue after that on the outside, but it does cause a little bit more pain and sometimes patients will kind of lean more towards a 10-day time off work after that.

Interviewer: When I'm going in for my day of surgery I'm going to have somebody drive me. Hopefully I've already gotten my prescriptions. Do I need an overnight bag?

Dr. Orlandi: Nope, this is a surgery that's called an outpatient surgery. You come in and go home the same day. Sometimes patients will need to spend the night if they have another condition like sleep apnea or something like that, and that's discussed with the anesthesiologist, but most often this is something that's done in and out the same day, and when the patients do have to spend the night we make those plans ahead of time and so they know that.

Interviewer: For that person that's going to pick me up, can they just wait? Is it that quick of a procedure or should they go do something else?

Dr. Orlandi: It actually depends. There are four sinuses on either side and your surgeon may chose to operate on only one or all eight, so it really depends on the extent of the procedure. This is not a life-threatening surgery so people don't have to wait in vigil in the family waiting room. If they want to go and do something else, we'll call them ahead of time to come pick you up. That's certainly fine, too.

Interviewer: So it sounds like a question to ask and just something to be aware of.

Dr. Orlandi: Absolutely.

Interviewer: What other things do you tell your patients when it comes to preparing for the surgery?

Dr. Orlandi: You know, I think we've covered it. I think again that the most important point is to make sure you're comfortable with your decision. Don't feel rushed into this. This is something that you can take your time deciding on.

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Interviewer: You had your sinus surgery and now it's afterwards and you've probably got a lot of questions. What's going to happen during your recovery, what do you need to do or avoid, and what are some common questions and issues that generally arise? That's what this podcast is going to talk about, after your sinus surgery.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: We're with Dr. Richard Orlandi. He's one of the experts here at University of Utah Healthcare and Sinus Surgery, and I think the first concern people would have after surgery is what am I going to look like? Am I going to be bandaged up? Am I going to have bruises? Is it going to look like I went through something major?'

Dr. Orlandi: That's a really important point. The thing to remember with any surgery that's happening just inside the nose, is no, you are not going to have bruises and you're not going to have a cast on your nose. If work is being done to change the outside appearance of your nose or a much more extensive procedure is being done to straighten out the inside of your nose, what we call the septum, the wall between the left and right side, then yes, that might happen. Hopefully, your surgeon is going to discuss that with you ahead of time. But for the vast majority of sinus surgeries, no, you're not going to be able to look at someone and tell that they had it done even hours or days later.

Interviewer: Did that not used to be the case?

Dr. Orlandi: That definitely did not used to be the case. When we were making incisions under the lip or between the eyes and the nose, quite a bit of bruising was going on. Now with everything being done with fiber optic scopes through the nostril, that's the endoscopic part of endoscopic sinus surgery, we're not seeing that happen.

Interviewer: A next question a patient probably is going to have is how long until I can . . . fill in the blank. Go back to work, exercise, smell the roses . . .

Dr. Orlandi: Let's go in the order of when these things are going to happen. Right after sinus surgery, because the nose has such a rich blood supply, we don't really want to get the heart pumping and the blood pressure up because it's going to cause the nose to bleed a little bit more. So we're going to hold off on vigorous exercise for three to five days. What I tell patients is, "Go ahead and go out for a jog when you feel up to and if your nose starts bleeding, stop and try again a day or two later." It's a little bit of trial and error but we typically want to hold off on that.

Going back to work, I think about a week is pretty standard. If we're doing work on the septum to straighten out the inside of the nose then we're going to wait about 10 days on average. Stopping and smelling the roses, a lot of times sinus problems can cause a reduction in the sense of smell. That can take a little while to come back, more on the order of two to three weeks or even longer for that to come back. Sometimes it doesn't come back all the way and that's really frustrating. That's a big quality of life issue. If you can't smell your food, much of what we perceive as taste is actually smell. Our patients are really concerned when they can't smell and taste very well because it does impact their enjoyment of food.

Interviewer: You've given us an indication of how long you should wait until you can do some common things. You said about a week off of work to recover. What am I doing in that week? Why can't I go back right away?

Dr. Orlandi: Most of the time patients are still having a little bit of discomfort or pain. They may still feel a little bit out of it just from having the surgery. It's right in between your eyes and so it's hard to ignore. Concentration can be an issue.

I've seen patients go back to work two days after surgery. I've seen patients go back to work two weeks after surgery. Everyone is different, but on average you're feeling just a little bit out of it and maybe sitting on the couch and watching ESPN is the better thing to do for a few days.

Interviewer: What does recovery look like? We already talked that we're not going to look like that preconceived notion that somebody punched me or beat me up with the bandages and the [inaudible 00:03:48], but what about bleeding and changing bandages and that sort of thing?

Dr. Orlandi: The inside of the nose doesn't look as good as the outside. There are a lot of raw surfaces. There is a little bit of oozing, and patients, especially for the first day, may wear a bandage or a piece of gauze underneath their nose with some tape going up to the face to try to catch that blood as it comes out. That'll diminish usually in 24 hours after the surgery and that won't be necessary.

One of the critical things that we encourage our patients to do is to rinse their nose out with salt water after surgery. I'm not talking a little misting spray. We're talking a quarter cup or a half of cup of saltwater in the nostril where the surgery was done, and on both sides, obviously, if the surgery was on both sides. That's going to rinse out a lot of that blood and secretions that can accumulate during the surgery.

That blood and secretions need to come out one way or the other, so I'd rather have the patients remove it day-to-day at home rather than have it have to be removed in the office. That is not comfortable at all.

Interviewer: And pretty crucial to the healing process that that gets out of there?

Dr. Orlandi: It is, because that accumulated blood can lead to scar tissue if it's not removed, and then that can block off the sinuses and then we're back to square one.

Interviewer: Gotcha. Are there any other really important parts of recovery that you should take seriously? Rinsing the nose sounds pretty important.

Dr. Orlandi: That's really the big one, frankly. We do put patients on antibiotics sometimes after surgery and we want patients to continue those. Obviously, patients will take their pain medicine as they need to. Those are really the big things. And then as we talked about, some exercise restrictions to not make things worse.

Interviewer: What does a timeline look like as far as getting back to normal? I'd imagine things are worse before they get better.

Dr. Orlandi: There is one other thing and it sounds so weird, but we ask patients not to swim for four weeks after surgery because chlorinated water can irritate the sinuses. Other than that, no. I think patients can expect to feel worse than they did before surgery for about three weeks. At about three weeks they can often feel about the way they did before surgery, and then we hope that that improvement continues and they steadily feel better afterwards.

The healing from sinus surgery, meaning the recovery back to normal, can take weeks to months. Now you may feel largely back to normal after three weeks to month, but that healing actually takes up to a year so there's going to be quite intensive care afterwards until we get to a point about a year after surgery where we're into the smooth sailing area.

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updated: November 9, 2018
originally published: February 5, 2015